Myocardial Infarction Mortality in Rural and Urban Hospitals: Rethinking Measures of Quality of Care

Abstract

PURPOSE Patients with acute myocardial infarction have higher mortality rates in rural hospitals than in urban hospitals, suggesting substandard quality of care in the rural setting. We examined characteristics of patients experiencing myocardial infarction and used an instrumental variable technique to adjust for unmeasured confounding when comparing mortality rates for these hospitals. RESULTS Unadjusted and risk-adjusted mortality rates using logistic regression models indicated signifi cantly lower in-hospital mortality for patients with myocardial infarction admitted to urban hospitals than for their counterparts admitted to rural hospitals (unadjusted values, 6.4% vs 14%). The urban and rural groups differed signifi cantly on characteristics studied, however. Analyses indicated that the traditional logistic regression models were possibly confounded by unmeasured patient factors, and when the same data were analyzed with the instrumental variable technique, mortality differences disappeared. METHODSCONCLUSIONS In Iowa, mortality from myocardial infarction in rural hospitals is not higher than that in urban ones after controlling for unmeasured confounders. Current risk-adjustment models may not be suffi cient when assessing hospitals that perform different functions within the health care system. Unmeasured confounding is a major concern when comparing heterogeneous and undifferentiated populations.

In-hospital case fatality rates for acute myocardial infarction in Romania

“…Usual practice dictates that patients be transferred to regional county referral hospitals or to tertiary referral hospitals, where intensive coronary care units and advanced technologies are available. 11 In this study, we examined in-hospital mortality rates after myocardial infarction in 21 county hospitals and 7 tertiary referral hospitals in Romania. We interpreted the mortality rates in light of the available evidence on the burden of traditional risk factors and practice patterns for cardiovascular medical care in Western Europe and the United States.…”

Characteristics, Drug Therapy, and Outcomes From a Database of 500,000 Hospitalized Patients With a Discharge Diagnosis of Heart Failure

“…In lieu of the availability of specific patient characteristics for assessment of HF severity, a Charlson Comorbidity Index (CCI) level was assigned to each patient. [14][15][16][17][18][19] The CCI includes 19 conditions. Each condition has a weight assigned from 1 to 6, which was derived from relative risk estimates of a proportional hazard regression model using clinical data.…”

Hospital Remoteness And Thirty-Day Mortality From Three Serious Conditions

“…When compared with urban hospitals, rural hospitals had higher mortality rates among patients hospitalized for AMI in one study but not in another. 6 Another study found higher mortality rates after percutaneous transluminal coronary angiography (PTCA) among patients hospitalized for AMI at rural hospitals, but similar rates among patients without AMI. 7 The absence of a national database and the small samples of patients within many rural institutions have made it difficult to compare the experiences of patients in rural hospitals and other settings.…”